Orientador: Paulo Dalgalarrondo / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-07-23T09:48:59Z (GMT). No. of bitstreams: 1 Dittmar_WulfHermann_D.pdf: 6688964 bytes, checksum: df4217a398689ff9f9951074819e470a (MD5) Previous issue date: 1997 / Resumo: É apresentado um estudo sobre a ansiedade em pacientes esquizofrênicos. Foi realizada uma observação transversal em 40 pacientes que preenchiam os critérios diagnósticos para a esquizofrenia segundo o DSM-IV, fora de surto agudo, e que estavam em acompanhamento clínico em quatro hospitais-dia do município de São Paulo. Foram incluídos pacientes de ambos os sexos, independentemente da idade, tempo de doença ou da medicação em uso. No protocolo de pesquisa foram investigadas as seguintes variáveis de estudo: 13) o estado de ansiedade (Escala de Ansiedade de Hamilton); 23) a categorização de uma desordem de ansiedade (critérios diagnósticos do DSM-IV); 33) a psicopatalogia (PANSS - Positive and Negativ Syndrome Scale); 43) o estado cognitivo (MMSE - Mini Mental State Examination); 53) sintomas depressivos (Escala de Calgary para a avaliação de depressão em pacientes esquizofrênicos); 63) a acatisia (Escala de Barnes para Acatisia); 73) efeitos colaterais devido ao uso de antipsicótico (Escala de Chouinard para a avaliação de efeitos colaterais da medicação neuroléptica); e 83) eventos biográficos recentes (uma versão reduzida da escala Holms-Rahe). Mediante a aplicação da Escala de Ansiedade de Hamilton, foram encontrados consistentes sinais e sintomas de ansiedade na maioria dos pacientes (média 14,0; s = 7,6). Nesta avaliação, em geral, houve um predomínio de sintomas psíquicos sobre os fisicos. Na maioria dos pacientes (52,5%) foi diagnostieada uma desordem de ansiedade (comorbidade), prevalecendo o pânico com e sem agorafobia (35%), a fobia social (27,5%), a ansiedade generalizada (27,5%), transtorno obsessivo-compulsivo (10%). Entre os pacientes com diagnósticos de desordem de ansiedade, a minoria (38%) tinha um diagnóstico único, sendo mais comum a descrição de mais de um diagnóstico. Os sintomas de ansiedade (estado de ansiedade) estão mais presentes entre os pacientes com o diagnóstico de esquizofrenia paranóide (295.30 - DSM-IV), sendo identificada a sua correlação com os sintomas positivos da escala P ANSS. No bloco de sintomas positivos foram encontradas correlações entre a ansiedade e os itens P6 (Desconfiança/perseguição) e P3 (Comportamento alucinatório). Os sintomas negativos não mostraram possuir particular correlação com os sintomas da ansiedade, mas também não inibem a sua manifestação. Na escala de psicopatologia geral foi encontrada uma correlação positiva entre a ansiedade e o item G16 (Esquiva Social Ativa). Os sintomas depressivos tiveram ampla sobreposição com os ansiosos, sendo que, na maioria dos casos (52%), estavam presentes na mesma proporção. O uso de medicação neuroléptica, por si só, não eleva os níveis de ansiedade, porém foi encontrada correlação positiva entre os seus efeitos colaterais e os níveis de ansiedade. Os pacientes que faziam uso de medicação benzodiazepínica apresentaram níveis significativamente mais baixos de ansiedade. Com exceção da ansiedade generalizada, mais freqüente entre os diagnósticos de esquizofrenia paranóide, as outra formas de desordem de ansiedade foram encontradas em igual freqüência entre os diferentes subtipos clínicos de esquizofrenia. É discutida a validade da comorbidade entre a esquizofrenia e as diferentes desordens de ansiedade, particularmente da fobia social, cujo componente delirante é inegável e que levanta dúvidas sobre a sua consistência diagnóstica / Abstract: A study on anxiety in schizophrenic patinets, envolving a cross sectional observation of 40 patients fulfilling the DSM-IV diagnostic criteria for schizophrenia, is reported. Theses patients were not in acute episode and the clinical follow-up was done in four day-hospitals in the municipality of São Paulo. Both sexes were included in the study, independently of age, time of disease, or mediaction being used. The variables included in the study's protocol were: I) anxiety state (Hamilton's Anxiety Scale); 2) categorization of an anxiety disorder (DSM-IV diagnostic criteria); 3) psychopathology (PANSS - Positive and Negative Syndrome Scale); 4) cognitive state (~1NSE - Mini Mental State Examination); 5) depressive symptoms (Calgary Scale for evaluation of depression in schizophrenic patients); 6) akathisia (Barnes Akathisia Rating Scale); 7) si de effects caused by the use of antipsychotic drug (Chouinard Scale for the evaluation of neuroleptic side effects); and 8) recent biographical events (a reduced version ofthe Holms-Rahe scale). Consistent anxiety signs and symptoms were found in most patients by using the Hamilton' s Anxiety Scale (mean = 14.0; sd = 7.6). Psychic symptoms prevailed over the physical symptoms. An anxiety disorder (comorbidity) was diagnosed in most patients (52.5%), the most prevalent being panic with and without agoraphobia (35%); social phobia (27.5%), general anxiety (27.5%), obsessive-compulsive disorder (10%). Among patients with anxiety disorder diagnosis, than a single diagnosis (38%) was less fTequent than the description of more than one diagnosis. The an.xiety symptoms (anxiety state) are more present in patients with diagnosis of paranoid schizophrenia (295.30 - DSM-IV), and their correlation with the positive symptoms of P ANSS scale was identified. Correlation between anxiety and items P6 (Suspiciousness/ persecution) and P:: (Hallucinatory behavior) were found in the block of positive symptoms. Nagative symptoms did not show any particular correlation with anxiety symtoms but did not inibit their manifestation. A positive correlation was round in general psychopathology between anxiety and iem Gl6 (Active social avoidance). There was a large overlapping between depressive and anxiety symptoms and in most cases (52%) they were present in the same proportion. The use of neuroleptic drugs, by itself, dose not increase the anxiety levels, but a positive correlation was found between their side effects and the anxiety levels. Patients using benzodiazepines had significantly lower anxiety levels. Exept for general anxiety, more fTequent among the paranoid schizophrenia diagnosis, the other forms of anxiety disorders were found with the same fTequency among the various schizophrenia subtypes, The validation of comorbidity between schizophrenia and various anxiety disorders is discussed, particulary in relation to social phobia where the delirious component is undiniable, raising doubts about its diagnostic consistency / Doutorado / Doutor em Saude Mental

Orientador: Luiz Roberto Monzani / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Filosofia e Ciencias Humanas / Made available in DSpace on 2018-08-03T20:32:21Z (GMT). No. of bitstreams: 1 Lima_IsabelCastelloBranco_D.pdf: 9707267 bytes, checksum: 001fe8c54e049884a226a487db3811e0 (MD5) Previous issue date: 2003 / Resumo: O trabalho analisa a construção freudiana do conceito de sexualidade no período compreendido entre a redação do relatório acadêmico de Freud sobre seus estudos com Charcot em Salpêtrière, em 1886, e a publicação dos "Três ensaios sobre teoria sexual", em 1905. Desde os primeiros textos, pautados pelo interesse em seguir a orientação das pesquisas de Charcot em relação à histeria, as investigações etiológicas são paulatinamente determinadas pela importância dos fenômenos psíquicos, entre os quais tomam-se fundamentais a noção de trauma e os fatores sexuais. Essas investigações estarão marcadas por uma concepção do sexual como "causa externa" dos fenômenos psicopatológicos; no entanto, a crescente complexidade da teoria designará um outro tipo de determinação à relação entre sexualidade e patologia. Percurso cuja construção é acompanhada por meio do exame da formulação inicial dos raciocínios próprios ao campo da etiologia das neuroses, de sua gradativa reorganização até o abandono da teoria da sedução e a conseqüente reorientação das investigações etiológicas, que exigem uma teoria da sexualidade articulada à constituição do psiquismo. Trata-se, portanto, da análise da trama conceitual na qual se inscreve a passagem da concepção dos fatores sexuais, ou da "vida sexual", como "causa específica" das neuroses à formulação do caráter constitutivo da sexualidade, descrito em sua dimensão formativa e, enquanto tal, determinante dos fenômenos psíquicos normais e patológicos / Abstract: This work analyzes the Freudian construction of the concept of sexuality in the period between Freud's writing of his academic report on his studies with Charcot, in Salpêtriere, in 1886, and the publication of the "Three essays on the theory of sexuality," in 1905. Ever since the first texts, guided by the interest in following Charcot's research on hysteria, the etiological investigations were gradually and increasingly determined by the importance of psychic phenomena, among which the notions of trauma and sexual factors become fundamental. These investigations are marked by a conception of sexuality as the "external cause" for psychopathological phenomena; however, the increasing complexity of the theory would designate another type of determination to the relationship between sexuality and pathology. The construction of this course is followed through the examination of the initial formulation of the rationales that belong to the field of the etiology of neuroses, from its gradual reorganization through the abandonment of the theory of seduction and the consequent reorientation of the etiological investigations that require a theory of sexuality articulated with the construction of psychism. This is, therefore, the analysis of the conceptual scheme that marks the passage of the conception of the sexual factors, or of "sexual life", as the "specific cause" of neuroses, to the formulation of the constitutive character of sexuality, described in its formative dimension and, as such, determining of the normal and pathological psychic phenomena / Doutorado / Doutor em Filosofia

Orientador: Dorgival Caetano / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-07-19T12:13:06Z (GMT). No. of bitstreams: 1 Cunha_JulianaRodrigues_M.pdf: 1960068 bytes, checksum: e821e8744039caa50ec2e13f3bbb676e (MD5) Previous issue date: 1994 / Resumo: O Distúrbio Obsessivo Compulsivo (DOC) é um dos quadros psiquiátricos de mais dificil compreensão. Os estudos que caracterizam os pacientes adultos com DOC são poucos e esse número é ainda mais limitado quando nos referimos a pacientes com diagnóstico de DOC pelo DSM-IIIR. Diante disso, o presente estudo foi realizado com o objetivo de descrever as características sócio-demográficas e clínicas de 50 pacientes. Foram estudados os prontuários de 50 pacientes com DOC, as lacunas foram preenchidas através de contato por telefone, carta e quando possível entrevista direta dos pacientes. Os instrumentos utilizados foram um questionário e o Yale-Brown check-list. Apesar das limitações do nosso estudo, os resultados foram, em geral, consistentes com os achados prévios da literatura, mostrando uma consistência entre as culturas: quadro de início precoce; acometimento ligeiramente maior do sexo feminino; intervalo prolongado entre o início dos sintomas e a época do 1º tratamento; comprometimento significativo do funcionamento, chegando, às vezes, a impedir a execução de atividades sociais e/ou ocupacionais do indivíduo; as obsessões mais comuns são as de contaminação e agressão; e as compulsões são de verificação e limpeza; ocorrência frequente de mais de um tipo de obsessão e/ou compulsão; elevada frequência de DOC entre parentes de 1º grau; resultados terapêuticos que, na maioria das vezes, variavam entre 41 a 80%, com o uso de inibidores da recaptação de serotonina. Ressalte-se a elevada frequência de suicídio (1 %) entre os parentes de 1º grau dos pacientes. Esse achado necessita ser replicado e melhor estudado / Abstract: The obsessive compulsive disorder (OCD) is one of the psychiatric disease most difficult to understand. The studies about adult OCD patients are few and they can be even fewer if we consider patients whose ondiction has been diagnosed according to the DSM-III-R. This study has been written with the aim of describing the socialdemographic and clínical characteristics of 50 patients. The files of 50 OCD patients were studied the missing information have been supplied through telephone calls, letters and, whenever possible, by means of a personal interview. Questionnairies and the Yale-Brown Check-list were used. Despite the short-comings of our study the results were, in general, consistent with what had previously been reported in the literature showing a number of similarities among the cultures such as early onset, a long period between the onset and the need to look for treatment, usual existence of more than one type of obsession and/or compulsion - the most ftequent obsessions being the fear of contamination and aggression and the most ftequent compulsions being checking and cleaning - and high rate of OCD among first-degree relatives. It shoud also be emphasised the high rate of suicides (1 %) among the patients' first-degree relatives. This fact should be checked and looked into more deeply / Mestrado / Mestre em Saude Mental

Prospective observational research over a period of three years. Based on a 722 patient sample hospitalized at the acute unit of the Parc Hospitalari Marti i Julià at the Institut d’Assistència Sanitària. Since admission, a number of variables from clinical records which might represent aggressiveness risk factors were collected along with more data taken during their stay recorded under Overt Aggression Scale (OAS) surveillance.An scale has been built formed by the combination of the static risk factors (age, former violence, civil status, drug consumption and dynamic risk factors (irritability, motor activity, awareness of the illness) than has an AUC value of 0,854, sensibility of 82%, a specificity of 73%, a positive predictive value of 62% and negative predictive value of 88% at the cut point 3-4 to determine the global violence. / Estudi observacional prospectiu dut a terme durant tres anys. La mostra és de 722 pacients que van ingressar al servei d’aguts de psiquiatria del Parc Hospitalari Martí i Julià de Salt de l’Institut d’Assistència Sanitària. En el moment de l’admissió, es van recollir de la història clínica un conjunt de variables que segons la literatura poden ser factors de risc d’agressivitat i al llarg de tot el període d’ingrés, es van registrar els incidents d'agressivitat amb la Overt Aggression Scale (OAS).S’ha construït una escala formada per la combinació de factors de risc estàtics (edat, violència anterior, estat civil, consum de tòxics recent) i factors de risc dinàmics (irritabilitat, suspicàcia, activitat motora, consciència de malaltia) que té un valor AUC de 0,854, sensibilitat del 82%, una especificat del 73%, un valor predictiu positiu del 62% i un valor predictiu negatiu del 88% en el punt de tall 3-4 per determinar el risc de violència global.

Tesi realitzada a l'Institut Clínic de Neurociències - Hospital Clínic de Barcelona. / La fibromiàlgia és una síndrome freqüent que cursa amb dolor crònic generalitzat i altres símptomes com fatiga, alteracions afectives i de la son, alteració d'algunes capacitats cognitives i una notable disminució de la capacitat funcional i interferència en les àrees vitals de l'individu que la pateix. Malgrat els notables avenços científics que s'han assolit en el coneixement d'aquesta síndrome, tant la pròpia fibromiàlgia com els pacients segueixen patint un descrèdit que agreuja el seu patiment i dificulta les relacions amb el sistema sanitari i els serveis socials. Al nostre parer, aquest descrèdit està relacionat, entre d'altres, amb els dubtes sobre la ubicació nosològica de la fibromiàlgia, la manca de credibilitat de la gravetat dels símptomes referits pels pacients i les sospites de simulació, i les explicacions de la malaltia basades en suposades característiques específiques de personalitat que propicien un major dramatisme, impacte de les demandes de l'entorn i un maneig inadequat d'aquests requeriments contextuals. Per tant, els objectius dels estudis d'aquesta tesi s'han dirigit a verificar la possibilitat de diferenciar la fibromiàlgia d'altres trastorns per dolor crònic de presentació clínica similar i de la simulació, a avaluar l'existència de característiques de personalitat pròpies de la fibromiàlgia i, per tant, diferents d'altres trastorns per dolor crònic i d'una malaltia crònica que no cursa amb dolor crònic. Tanmateix, ens va interessar complementar aquest objectiu amb l'avaluació de la influència de les característiques de personalitat dels pacients amb fibromiàlgia en la resposta a un tractament multidisciplinari. Els resultats suggereixen que tant en població espanyola com llatinoamericana, la fibromiàlgia és distingible d'altres trastorns per dolor crònic sobre la base de la simptomatologia somàtica, depressiva i ansiosa, el grau de catastrofisme i la incapacitat funcional que comporten. Aquesta diferenciació no només dona suport a la definició de la fibromiàlgia com una entitat discreta sinó que també facilitaria la seva detecció i tractament precoços. Així mateix, la fibromiàlgia sembla distingible de la simulació tant si l'objectiu del pacient és iniciar un tractament com sol•licitar una compensació econòmica per invalidesa. Aquesta troballa no només contribueix a corregir l'atribució dels símptomes de la fibromiàlgia a motivacions per obtenir beneficis secundaris de tipus econòmic sinó que també pot ajudar a la necessàriament minuciosa tasca de detectar la simulació. Finalment, no es va observar un perfil específic de personalitat en la fibromiàlgia un cop controlat l'efecte de variables de confusió com l'estat psicopatològic. La personalitat va permetre, no obstant, definir dos subgrups de pacients amb diferent resposta al tractament. Aquesta agrupació podria contribuir a millorar el tractament ajudant a dissenyar intervencions més específiques i a millorar altres variables implicades en el procés terapèutic com el compliment de pautes, l'aliança terapèutica o la seqüenciació del tractament. / Fibromyalgia is a common syndrome characterized by widespread chronic pain along with other accompanying symptoms such as fatigue, emotional and sleep disorders, cognitive dysfunction and a remarkable increase of disability and interference in psychosocial domains. In spite of the significant advances in the scientific knowledge of this syndrome attained in recent years, both patients and the diagnosis of fibromyalgia itself endure a discrediting that may worsen patients' suffering and hamper their relations with the health system and social services. In our opinion, this discrediting may be related, among others, to doubts about the legitimacy of the nosologic status of fibromyalgia, suspicions that symptoms are exaggerated or simulated, and explanations of the onset and maintenance of the syndrome based on presumed specific characteristics of personality that foster an abnormal impact of contextual demands and a lower coping ability. Therefore, the studies of this thesis are aimed at assessing: a) if the clinical presentation of the fibromyalgia syndrome is different enough from that of other chronic pain disorders, thus suggesting that fibromyalgia is better understood as a discrete clinical entity; b) if the psychopathological profile observed in fibromyalgia patients allows differentiating them from cases of simulation; and c) if fibromyalgia patients are characterized by a specific personality profile, if personality profiles allow defining subgroups of patients, and if every subgroup shows a different therapeutic response to multidisciplinary treatment. Our results suggest that both in Spanish and Latin American samples, fibromyalgia is distinguishable from other chronic pain disorders on the basis of somatic, depressive and anxiety symptoms, catastrophizing and functional disability. Likewise, fibromyalgia is reliably distinguishable from simulation both if patients have initiated a legal process aimed at obtaining compensation for disability or not. Finally, fibromyalgia patients did not show a specific personality profile once controlled the effect of confusion variables such as psychopathology. The personality assessment allowed, however, the definition of two subgroups of patients showing different therapeutic responses.

La recerca en els darrers anys ha demostrat que el pacient amb trastorn bipolar (TB) no està lliure d'afectació neurocognitiva i que aquesta pot tenir una repercussió important en el seu funcionament quotidià. Pel que fa al trastorn bipolar tipus II (TB-II), atès que ha patit una manca d'atenció i durant molt de temps ha estat un subtipus infradiagnosticat, els treballs dirigits a aspectes neuropsicològics han estat escassos amb resultats discrepants i no concloents. Per tant, cal dur a terme estudis centrats en aquesta població específica per tal d'establir de manera adequada el seu perfil neurocognitiu donades les implicacions clíniques i terapèutiques que se'n poden derivar. En aquesta tesi es du a terme una revisió sistemàtica (primer estudi) de la literatura existent per a veure quin és l'estat actual d'aquesta temàtica. A partir d'aquesta s'estableixen les bases per a la recerca posterior, amb l'objectiu de determinar els principals dèficits neurocognitius associats al TB-II avaluant pacients amb criteris rigorosos d'eutímia. Amb el segon estudi es va detectar que els pacients TB-II en remissió presenten un rendiment neurocognitiu inferior als subjectes sans tant en el domini d'atenció com en els de memòria verbal, memòria de treball i funció executiva. En segon lloc s'intentaven identificar possibles predictors del funcionament psicosocial a partir de l'estudi de variables clíniques, sociodemogràfiques i neurocognitives. Es va observar que les disfuncions executives i la presència de simptomatologia subclínica de caire depressiu podrien ser útils com a predictors d'un major deteriorament funcional en aquest grup. Posteriorment, ens varem proposar estudiar si existeix heterogeneïtat neurocognitiva entre aquesta subpoblació amb un tercer estudi. Es va observar que existeixen diversos subgrups amb perfils neurocognitius diferenciats entre els pacients; pacients amb un rendiment neurocognitiu totalment preservat, pacients amb alteracions moderades-greus en tots els dominis cognitius (amb excepció de la memòria verbal amb dèficit lleu) i pacients amb un rendiment intermedi amb alteracions (leus. Més d'un 50% dels pacients TB-II presentaven dificultats neurocognitives. Cap variable clínica relacionada amb la severitat o cronicitat de la malaltia podia explicar les diferències entre subgrups. Aquells pacients amb un rendiment neurocognitiu deficitari global presentaven un QI més baix, un pitjor funcionament psicosocial global i majors dificultats per a realitzar i gaudir de les activitats de lleure. En darrer lloc, cal tenir present que és necessari oferir als pacients un tractament integral de la malaltia on es contemplin també les dificultats neurocognitives i de funcionalitat, oferint, per tant, noves estratègies d’intervenció que permetin millorar aquests aspectes. D’aquesta manera, amb el darrer estudi (quart estudi) s’avaluava l’eficàcia d’una nova estratègia d’intervenció neurocognitiva, la rehabilitació funcional, específicament en un grup de pacients TB‐II també eutímics, valorant l’impacte que aquesta intervenció podia exercir sobre el funcionament psicosocial dels pacients. La rehabilitació funcional va mostrar ser efectiva no només millorant el funcionament general sinó també reduint la simptomatologia subclínica depressiva dels pacients TB‐II. / Patients with Bipolar Disorder (BD) show broad cognitive impairments that persist during euthymia despite remission of mood symptoms. Cognitive deficits in BD are associated with impairments in functional outcome and quality of life. Thus, improving cognitive functioning is an important treatment goal in people with BD. Bipolar II disorder subtype (BD-II) has been underdiagnosed in clinical practice, therefore, many aspects of BD-II are still understudied such as neurocognitive functioning. In the present thesis, a systematic review of literature regarding neurocognition in BD-II was carried out. Then, we assessed a sample of strictly defined BD-II euthymic patients to compare it with a sample of healthy controls (HC) to elucidate the neuropsychological profile of this bipolar subtype. A second objective was to study the relationship between neurocognitive performance and functional outcome. BD-II patients showed a significantly lower performance on several measures of attention, learning and verbal memory, and executive function compared with HC. The presence of subthreshold depressive symptomatology and one measure related to executive function and working memory were the variables that best predicted psychosocial functioning. After that, we attempted to analyse cognitive variability also in a sample of euthymic BD-II patients, using a cluster analysis to provide groups of different neurocognitive patterns. Three clusters were detected: an intact neurocognitive group, an intermediate or selectively impaired and a globally impaired group. Approximately one-half of the patients were cognitively impaired. The 3 clusters statistically differed in the premorbid intelligence quotient, the global functional outcome and leisure activities. The globally impaired cluster showed the lowest attainments concerning these 3 variables, which are considered proxies of cognitive reserve. No differences in other clinical characteristics were found among the groups. Taking all these data into account, it seems necessary to implement therapies focused on enhancing functional outcome in bipolar II disorder patients. Hence, we carried out a subanalysis aimed to assess the efficacy of an intervention called Functional Remediation specifically in a sample of BD-II patients. Our results suggest that the Functional remediation appears to be effective in improving the overall functional outcome in BPII, as well as in reducing subclinical depressive symptoms.

La tesis doctoral presenta el diseño del primer protocolo de intervención del juego patológico en pacientes con esquizofrenia y desarrolla el primer estudio controlado que realiza este tipo de terapia. La investigación cuenta con 44 pacientes duales que se dividen en un grupo experimental (23 sujetos) que recibe tratamiento psicológico y en un grupo de control (21 sujetos) que permanece 3 meses sin intervención psicológica. La tesis doctoral cuenta con diferentes objetivos principales: 1) Comprobar la efectividad del programa de tratamiento psicológico cognitivo-conductual para la ludopatía en un formato mixto (individual y grupal) diseñado específicamente para pacientes duales y aplicado en diversos dispositivos de Salud Mental (régimen ambulatorio y de ingreso). Los resultados obtenidos son satisfactorios, ya que el grupo experimental presenta un porcentaje de éxito superior (73,9%) al del grupo de control (19,0%) después del tratamiento y durante el seguimiento, evidenciándose la efectividad de la intervención terapéutica. 2) Conocer las características de los patrones de recaída de los pacientes duales de ambos grupos en el período de observación de 3 meses; y del grupo experimental durante el tratamiento (184 días) y el seguimiento (367 días). Los resultados obtenidos son positivos, ya que el grupo experimental en la observación de 3 meses recae menos que el grupo de control; en el tratamiento, el grupo experimental presenta 4 sujetos que recaen los primeros 30 días (17%), presenta un 65% de posibilidades de que no recaigan antes de 120-130 días y tienen una mediana de tiempo de abstinencia de 180 días, por lo que más de la mitad del grupo con tratamiento no recae en 6 meses; y en el seguimiento, el grupo experimental presenta 5 sujetos que recaen (25%), cuenta con un 90% de posibilidades de que no recaigan antes de 120-140 días y presentan una mediana de tiempo de abstinencia de 360 días, por lo que más de la mitad del grupo tratado no recae en 12 meses. 3) Obtener las posibles variables predictoras del riesgo de recaída en los pacientes duales. En este sentido, los resultados muestran que la edad de inicio de la conducta de juego (p=0,004) es la única variable predictora del riesgo de recaída, por lo que una mayor antigüedad en la conducta patológica de juego plantea mayor riesgo para recaer. 4) Analizar la evolución de los episodios de juego de los pacientes duales del grupo experimental en el tratamiento y el seguimiento. En esta línea, los resultados muestran una disminución del número de episodios de juego en relación con la evaluación pretratamiento, a partir de la observación postratamiento, y un mantenimiento de esta disminución en el seguimiento, aunque se produce un incremento moderado de los episodios de juego en el seguimiento de los 6 y 12 meses. 5) Recoger las variables más significativas de los pacientes duales de la muestra total. Los datos muestran que las variables demográficas más habituales son: sexo masculino (93,2%), edad 26-40 años (56,8%), estado civil soltero (81,8%), estudios primarios (72,8%), pensionista (86,4%), ingreso mensual 301-600 € (84,1%) y apoyo familiar (72,8%); las variables de consumo de sustancias psicoactivas más frecuentes son: no beber alcohol (56,8%), fumar 2-3 paquetes diarios (61,4%) y no ingerir otras sustancias tóxicas (88,6%); las variables de juego más usuales son: en una semana jugar 6-7 días (27,3%), dedicar 1 hora (43,3%) y gastar 12-30 € (31,8%); y las variables de la esquizofrenia más comunes son: presentar un curso de trastorno episódico con síntomas residuales interepisódicos (56,8%), desarrollar la enfermedad entre los 18-30 años (77,3%), contar con una antigüedad en la esquizofrenia superior a 15 años (52,3%) y presentar de 1-5 ingresos psiquiátricos (56,8%) por descompensación psicótica. / The thesis presents the design of the first protocol of intervention of pathological gambling (PG) in patients with schizophrenia (SZ) and develops the first controlled study that tests this type of therapy. In the research 44 dual patients are divided into an experimental group (EG) (23 subjects), receiving psychological treatment for PG, and a control group (CG) (21 subjects), remaining 3 months without psychological intervention. The main objectives are: 1) Determine the effectiveness of a cognitive behavioral treatment for PG in a mixed format, specifically designed for dual patients and applied in various facilities of Mental Health. The results are satisfactory, since the EG has a higher success rate (73.9%), than the CG (19.0%) after treatment and during follow-up. 2) Know the characteristics of patterns of relapse in dual patients in both groups in the observational period of 3 months; and in the EG during treatment (184 days) and monitoring (367 days). The results are positive, since the relapse rate of the EG in the 3-month observation is lower than the CG; in treatment, the EG has a 65% chance that do not relapse 120-130 days and has a median time of 180 days abstinence; and in monitoring, the EG has a 90% chance that do not fall before 120-140 days and has a median time of 360 days of abstinence. 3) Obtain the possible predictors of risk of relapse in dual patients. In this sense, the results show that the only predictor of the risk of relapse is the age of onset of gambling behavior (p = 0.004). 4) To analyze the evolution of the game episodes of dual patients in the EG in the treatment and the monitoring. Along these lines, the results show a decrease in the number of episodes of gambling relative to the pretreatment evaluation, from the post-treatment observation, and maintenance of the decrease in the follow up, while a moderate increase in episodes of gambling occurs in 6 and 12 months follow-up. 5) Collect the most significant variables (demographic, consumption of psychoactive substances, variables regarding PG and SZ) of dual patients of the total sample.

En esta tesis se muestran los resultados obtenidos con el programa de educación multidisciplinario para el tratamiento del sobrepeso y obesidad infantil "Niñ@s en Movimiento". Este es un programa estructurado de 11 semanas de duración, de formato grupal o individual, que consta de material educativo, tanto para el instructor como para los pacientes participantes, que servirán para ejecutar el programa. El material para el instructor, es un libro guía para poder llevar a cabo el tratamiento. El material para los niños son 10 cuadernos de trabajo, donde el niño los trabajará en casa y posteriormente en las sesiones de una hora y media semanal. Está dirigido a niños y niñas prepuberales de 6 a 12 años de edad con problemas de sobrepeso u obesidad exógena. Es un programa que tiene como objetivo realizar cambios sobre aquellos estilos de vida y hábitos alimentarios que contribuyen a la ganancia de peso, contemplando la educación en nutrición, la actividad física y la emocionalidad del niño. Utiliza técnicas cognitivo-conductuales y afectivas. Trabaja con temas relacionados con su salud como: Alimentación, publicidad engañosa, autocontrol, imagen corporal, comunicación, resolución de conflictos, asertividad, autoestima, relajación y actividad e inactividad física (horas de televisión y juegos de ordenador). Posibilita un espacio donde los niños puedan analizar y expresar sus emociones en relación con el tema del sobrepeso, obesidad y sus consecuencias.De acuerdo a los resultados obtenidos tanto en los parámetros antropométricos, psicológicos y en la calidad de la dieta mediterránea (se observó una disminución del IMC, un aumento en la calidad de la dieta mediterránea, una mejoría de los rasgos depresivos y de ansiedad y una mayor satisfacción corporal), el programa "Niñ@s en movimiento" puede ser un instrumento eficaz y de aplicabilidad fácil, útil ante la necesidad de implementar programas que ofrezcan soluciones a un problema que cada día se presenta con mayor frecuencia. / This thesis shows the results obtained from the multidisciplinary program of education for the treatment of the overweight and children's obesity " Niñ@s en Movimiento". The length of this program is 11 weeks, in which the sessions taken place are individual or in groups. Here, the instructor and the patients, who participate, use educational material in order to execute the program. The material used by the instructor is a Guide that will help to undertake the treatment. And the material used by the children consists of 10 workbooks. The workbooks will be done at home and afterwards at the weekly meetings during 1 hour and half. This program is addressed to boys and girls from 6 to 12 years old, whom have overweight or exogenous obesity problems. The purpose of this program is to achieve changes of lifestyle and eating habits that contribute to overweight, by taking into account nutrition education, physical activity and the child's emotions. It uses cognitive-behavioral and affective technologies. This program works with different elements related to the child's health such as nourishment, deceitful advertising, self-control, corporal image, communication, conflict resolutions, assertiveness, self-esteem, relaxation, movement and physical inactivity (watching hours of television and playing computers games). These children also have the opportunity to analyse and express their own emotions about their overweight, obesity ans its consequences.The results obtained from the anthropometric and psychological parameters plus the benefits of the mediterranean diet (were a decrease of the Body Mass Index, an increase of the quality of the mediterranean diet, an improvement of the depressive and anxiety symptoms and a positive vision of their self-image. The program "Niñ@s en Movimiento" can be an effective instrument and of easy aplication due to the need to implement programs that give solutions to a problem, which is becoming more frequent everyday.

El tratamiento de los pacientes con trastorno límite de la personalidad (TLP) es uno de los retos más difíciles para el psiquiatra en la práctica clínica. Su manejo es especialmente complejo en los servicios de urgencias psiquiátricas cuando acuden en situación de crisis y manifiestan los síntomas más severos como trastornos conductuales y elevado riesgo suicida. Según las recomendaciones de la Guía de la APA, el tratamiento principal para el TLP es la psicoterapia complementada con la farmacoterapia para aquellos síntomas que más alteran la calidad de vida. Sin embargo, hasta la fecha no existe ningún fármaco con la indicación oficial para el tratamiento del TLP. Aún sin indicación, en la práctica clínica los psiquiatras usan antipsicóticos para tratar pacientes con TLP especialmente en situación de crisis. Con la aparición de los antipsicóticos atípicos, se ha renovado el interés por su posible utilidad en el tratamiento del TLP. Los trabajos publicados hasta la fecha sugieren su posible eficacia, sin embargo, no existe un nivel de evidencia científica que apoye su recomendación. El objetivo general de la tesis es profundizar en el conocimiento de la práctica clínica habitual con pacientes con TLP en los servicios de urgencias y evaluar la efectividad de los antipsicóticos atípicos en el tratamiento de estos pacientes. Se han realizado trabajos observacionales que describen la práctica clínica que se realiza habitualmente en los servicios de urgencias psiquiátricas y ensayos clínicos farmacológicos con antipsicóticos atípicos.En primer lugar se analizó una muestra de más de 11.000 pacientes que acudieron a Urgencias de psiquiatría del Hospital del Mar durante 4 años. Se estudiaron las características clínicas y de manejo terapéutico de los pacientes diagnosticados de TLP incidiendo en los factores que predecían la necesidad de hospitalización como el riesgo de suicidio y de prescripción de fármacos. También se analizó la posible relación entre el fenómeno de la inmigración y el riesgo de ser diagnosticado de TLP. Destacó la menor prevalencia de TLP en pacientes inmigrantes y la importante influencia del lugar de origen del inmigrante en esta asociación ya que pacientes subsaharianos y asiáticos presentaron una tasa especialmente baja.A continuación se analizaron las características de los pacientes agitados que acudían a urgencias de psiquiatría del Hospital de la Santa Creu i Sant Pau y el manejo farmacológico que se realizaba. Destacó la elevada prevalencia de pacientes con diagnóstico de trastorno de personalidad (24%) y el elevado uso de antipsicóticos atípicos en la práctica clínica para tratar estos pacientes mostrándose como fármacos efectivos y seguros.Posteriormente se analizó la posible efectividad de los nuevos antipsicóticos atípicos en el tratamiento específico de pacientes con TLP. En primer lugar se realizó un estudio abierto no controlado con antipsicóticos atípicos intramusculares (olanzapina y ziprasidona) en el tratamiento de los pacientes con TLP que acudían a urgencias de psiquiatría en estado de agitación evidenciándose su utilidad y seguridad. Posteriormente, también se observó en un estudio no controlado la eficacia de la ziprasidona en pacientes con TLP que acudían a Urgencias en situación de crisis. Finalmente, ante las evidencias de eficacia en urgencias en estudios abiertos, se realizó un ensayo clínico controlado, aleatorizado, doble ciego y controlado con placebo para evaluar la eficacia de la ziprasidona en el tratamiento de mantenimiento de pacientes con TLP. En este estudio no se observaron diferencias significativas entre ziprasidona y placebo no mostrándose como un fármaco eficaz en el tratamiento de mantenimiento de pacientes con TLP. / The treatment of patients with Borderline Personality Disorder (BPD) is one of the most difficult challenges a psychiatrist faces in clinical practice. Its management is especially complex in the psychiatric emergency services when patients come in crisis and show the most severe symptoms such as conduct disorders and high risk of suicide. Following the APA guideline's recommendations, the primary treatment for BPD is psychotherapy complemented by pharmacotherapy targeted to the symptoms that affect the quality of life. However, still there is not an officially established drug for BPD treatment. But even without indication, in clinical practice the psychiatrists use antipsychotics for treating patients with BPD, especially in crisis. Since the atypical antipsychotics appearance there has been a renewed interest in its possible utility for treating BPD. The studies published to date suggest its possible effectiveness, however it does not exist enough scientific evidence that supports its recommendation. The general aim of the thesis is to deepen our knowledge about the usual clinical practice with BPD patients in emergency services and to assess the effectiveness of atypical antipsychotics in the treatment of these patients. There have been observational studies that describe the usual clinical practice carried out in the psychiatric emergency services and pharmacological clinical trials with atypical antipsychotics.Firstly, a sample of more than 11,000 patients that came to the psychiatric emergency service of the Hospital del Mar over 4 years was analysed. The clinical features and therapeutic management of patients diagnosed with BPD were studied, emphasizing on the predictive factors of hospitalization, like the risk of suicide, and drug prescription. The possible association between the immigration and the risk of being diagnosed with BPD was also analysed. It stood out the less prevalence of BPD among immigrant patients and the important influence of the immigrant's region of origin in this association as the Sub-Saharan and Asian patients showed an especially low rate.Next were analysed the characteristics of the agitated patients that came to the psychiatric emergency services of the Hospital de la Santa Creu i Sant Pau and the pharmacological management carried out. It was showed the high prevalence of patients diagnosed with Personality Disorder (24%) and the high use of atypical antipsychotics in clinical practice for treating these patients, showing its effectiveness and security.Subsequently, the possible effectiveness of the new atypical antipsychotics in the specific treatment of patients with BPD was analysed. Firstly, an open not controlled study was carried out with intramuscular atypical antipsychotics (olanzapine and ziprasidone) in the treatment of patients with BPD that came to the psychiatric emergency service in a state of agitation proving its usefulness and security. Later, in a not controlled study, it was also observed the effectiveness of ziprasidone in patients with BPD that came to the emergency services in crisis. Finally, based on the evidence of effectiveness in the emergency service in open studies, a randomized, double-blind, placebo-controlled clinical trial was carried out to assess the efficacy of ziprasidone in the maintenance treatment of patients with BPD. In this study no differences were observed between ziprasidone and placebo, showing it was not an efficacy drug in the maintenance treatment of patients with BPD.

According neuropathological research limbic changes occur in Parkinson's disease with and without dementia. Structural MRI have reported atrophy of limbic structures including amygadala and hippocampus, in both demented and non-demented PD patients; and a progression of limbic atrophy over time. In addition, atrophy of paralimbic areas (i.e. paracingulate gyrus) and limbic association cortex (i.e orbitofrontal cortex) has also been reported in PD. Functional studies have also reported limbic dysfunctions in Parkinson's disease. PET studies reported that orbitofrontal and amygdalar presynaptic dopaminergic functions are altered in early PD and a significant decrease in the metabolism of the medial OFC in a follow-up study of patients with early PD. fMRI studies showed an abnormal amygdalar response in PD while recognizing fearful faces and lack of activation in the right hippocampus and amygdala while perceiving odorant stimuli inside the scanner. Neuropsychological studies pointed out that the functions that are known to depend on the integrity of limbic system are impaired in Parkinson's disease even in the early stages of the disease. Specifically, it has been reported and impairment in verbal memory, recognition of facial expressions of emotions, decision-making and olfactory function. However, the neuroanatomical and neurofunctional correlates of these dysfunctions are not known or are poorly investigated. For memory functions, hippocampal and amygdalar volumes have been reported to correlate with memory impairment. For decision making and recognition of emotions there are no studies of its correlates; and for olfactory dysfunctions one study reported a correlations between this impairment and a reduced fractional anisotropy in the cerebellum.The general aim of this thesis is to investigate the neuroanatomical and neurofunctional correlates of declarative memory, decision-making, recognition of emotions and olfactory dysfunctions in PD. We hypothesized that all these dysfunctions are due to the limbic degenerative changes associated with PD. We used structural MRI (T1-weighted MRI and DTI), functional MRI (fMRI) and neuropsychological testing to assess declarative memory, emotional processing and decision-making, and olfactory function. Firstly, we focused on the hippocampal atrophy putatively related to declarative memory dysfunctions and PD, and a possible neuroradiological marker for the evolution to dementia. This issue was investigated in papers I and II. Secondly, we aimed to investigate structural correlates of deficits in the recognition of emotions, decision-making and olfactory dysfunction reported early in the disease course by means of VBM and DTI (paper III and IV). Finally in paper V the functional correlates of recognition memory were assessed using fMRI.The main conclusions of this thesis, derived from the five studies, can be summarized as follows:1) The pattern of atrophy in non-demented PD patients affects the anterior region of the hippocampus and progresses to the posterior part in demented patients but preserves the middle part of this structure. This pattern and evolution is similar to that seen in Mild Cognitive Impairment of amnestic type and Alzheimer's disease.2) Declarative memory dysfunctions in PD depend on the atrophy of the head of the hippocampus. 3) Patients with visual hallucinations present progressive hippocampal atrophy and also show widespread atrophy involving the limbic, paralimbic and neocortical areas in agreement with the evolution towards dementia. In contrast, patients without VH only show gray matter loss in the motor regions and their cognitive functions remain spared.4) Early PD patients present gray matter loss in some limbic regions. We observed gray matter loss in the amygdala and orbitofrontal cortex but not in the anterior cingulate, enthorrinal cortex and accumbes nuclei. These results only partially support the stages proposed by Braak.5) Impairment in decision-making and recognition of facial expressions of emotions occurs at early stages of PD. These neuropsychological deficits are accompanied by degeneration of orbitofrontal cortex (OFC) and amygdala. Bilateral OFC reductions are associated with impaired recognition of emotions, and gray matter volume loss in left lateral OFC is related to decision-making impairment in PD.6) PD patients presented abnormal white matter microstructural changes in several brain regions including cortical and subcortical areas early in the disease course. However, only reduction of fractional anisotropy in the white matter of the central olfactory areas, specifically the white matter adjacent to the gyrus rectus, is associated with olfactory dysfunction in PD patients.7) There is a disruption of functional networks involved in memory and default mode in early PD. / Está tesis está compuesta de 5 artículos originales y una revisión con un factor de impacto total de 14.441. A lo largo de los 5 estudios se abordan los correlatos neuroanatómicos y neurofuncionales de las disfunciones de memoria declarativa, emocionales y olfatorias en la enfermedad de Parkinson por medio de resonancia magnética estructural y funcional y una extensiva exploración neuropsicológica. En el primer y segundo estudio se aborda el estudio de la atrofia del hipocampo y su progresión a lo largo del tiempo (estudio transversal y longitudinal) mediante voxel-based morphometry. En el tercer estudio se abordan los correlatos de las disfunciones de toma de decisiones y reconocimineto de emociones en la enfermedad de Parkinson, encontrando una relación entre la atrofia de la corteza orbitofrontal y dichas funciones. En el cuarto estudio utilizamos diffusion tensor imaging para investigar las posible anormalidades microestructurales en el sistema central olfatorio y su relación con la identificación de olores en las fases inciales del Parkinson. Finalmente en el quinto estudio investigamos la conectividad funcional de areas cerebrales implicadas en la realización de una tarea de memoria, las cuales descubrimos que están alteradas desde las fases iniciales de la enfermedad.